ANES 1502 - M9 PPT: Hemodynamic Monitoring

1. Hemodynamic Monitoring
(ABP, CVP, Ao)
Anesthesia Technology Fundamentals
ANES 1502
College of DuPage
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2. What is Hemodynamic Monitoring?
• Non-invasive = clinical assessment & NBP
• Direct measurement of arterial pressure
• Invasive hemodynamic monitoring
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3. Noninvasive Hemodynamic Monitoring
• Noninvasive BP
• Heart Rate, pulses
• Mental Status
• Mottling (absent)
• Skin Temperature
• Capillary Refill
• Urine Output
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4. Proper Fit of a Blood Pressure Cuff
• Width of bladder = 2/3 of upper arm
• Length of bladder encircles 80% arm
• Lower edge of cuff approximately 2.5 cm above the antecubital
space
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5. Why A Properly Fitting Cuff?
• Too small causes false-high reading
• Too LARGE causes false-low reading
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6. Indications for
Arterial Blood Pressure
• Frequent titration of vasoactive drips
• Unstable blood pressures
• Frequent ABGs or labs
• Unable to obtain Non-invasive BP
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7. Supplies to Gather
• Arterial Catheter
• Pressure Tubing
• Pressure Cable
• Pressure Bag
• Flush – 500cc NS
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8. Supplies to Gather
• Sterile Gown (2)
• Sterile Towels (3)
• Sterile Gloves
• Suture (silk 2.0)
• Chlorhexidine Swabs
• Mask
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9. Leveling and Zeroing
• Leveling
• Before/after insertion
• If patient, bed or transducer move
• Zeroing
• Performed before insertion & readings
• Level and zero at the insertion site
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10. Potential Complications
Associated With Arterial Lines
• Hemorrhage
• Air Emboli
• Infection
• Altered Skin Integrity
• Impaired Circulation
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11. Documentation
• Insertion procedure note
• ABP readings as ordered
• Neurovascular checks every two hours (in musculoskeletal assessment of
HED)
• Pressure line flush amounts (3ml/hr)
• Tubing and dressing changes
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12. Central Venous Pressure Assesses…
• Intravascular volume status
• Right ventricular function
• Patient response to drugs &/or fluids
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13. Central Venous Pressure (CVP)
• Central line or pulmonary artery catheter
• Normal values = 2 – 8 mm Hg
• Low CVP = hypovolemia or ↓ venous return
• High CVP = over hydration, ↑ venous return, or right-sided heart
failure
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14. Leveling and Zeroing
• Leveling
• Before/after insertion
• After patient, bed or transducer move
• Aligns transducer with catheter tip
• Zeroing
• Performed before insertion & readings
• Level and zero transducer at the phlebostatic axis
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15. Phlebostatic Axis 15
• 4th intercostal space,
mid-axillary line
• Level of the atria
(Edwards Lifesciences, n.d.)

16. More on Leveling and Zeroing
• HOB 0–60 degrees
• No lateral positioning
• Phlebostatic axis with any
position (dotted line)
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(Edwards Lifesciences, n.d.)

17. Dynamic Flush 17
• Dynamic flush ensures the
integrity of the pressure
tubing system. Notice how it
ascends, forms a square
pattern - and bounces below
the baseline before returning
to the original waveform.
• Check dynamic flush after
zeroing any pressure
tubing system.

18. System Maintenance
• Change tubing and fluid bag q 96hrs
• No pressors through CVP port
• Antibiotics, NS boluses, blood, & IV pushes are allowed through
the CVP line
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19. Troubleshooting
• Improper set-up and equipment malfunction are the primary
causes for hemodynamic monitoring problems
• Retracing the set-up process or tubing (patient to monitor) may
identify the problem and solution quickly
• Use your staff resources: Help All, Charge Nurse, Educator,
Preceptors, MICU experts
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20. Troubleshooting
Damped Waveforms
 Pressure bag inflated to 300 mmHg
 Reposition extremity or patient
 Verify appropriate scale
 Flush or aspirate line
 Check or replace module or cable
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21. Troubleshooting
Inability to obtain/zero waveform
Connections between cable & monitor
Position of stopcocks
Retry zeroing after above adjustments
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22. Continuous Airway Pressure (Ao)
• Also known as Paw, Ao
• Purpose:
• Improves accuracy of hemodynamic waveform measurements
• Identification of end-expiration
• Positive waveform deflections = positive pressure ventilation
• Negative deflections = spontaneous inspiratory effort
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23. Supplies to Gather
• Pressure Cable
• Pressure Tubing
• Connector
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(Edwards Lifesciences, n.d.)

24. Setting up the Ao
• Discard infusion spike end & cap port
• Connect pressure tubing to vent tubing (using connector opposite
heating cable)
• Connect cables
• Zero the tubing (leveling not necessary)
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25. Troubleshooting Ao
• Do not prime tubing with fluids!
• Damping will occur with fluid or secretions
• To evacuate any fluids, disconnect pressure tubing from vent
tubing and push air through the pressure tubing with a 10 ml
syringe connected at one end until fluid-free
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26. Pressure Measurement
1. Record Ao and CVP on the same strip
2. Find end-expiration by drawing a
vertical line with a straight edge 200
ms prior to the rise or dip in Ao (1
large box) associated with a breath.
3. Draw a horizontal line through the
visually assessed average vascular
pressure starting at end-expiration
going backward 200 ms (1 large box).
4. Read the pressure at the horizontal
line.
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15
10
5
0
-5
CVP=13

27. 27
200 ms
Assist-Control
Ao
CVP
{200 ms{

28. 28
CPAP with Pressure Support
Ao
CVP
200 ms
{200 ms{

29. 29
CPAP without Pressure Support
Ao
CVP
200 ms
{
200 ms
{

30. 30
40
30
20
10
0
-10
Incorrect method!
This point was
identified as end-
expiration for a pt.
who did not have an
Ao set up.
Correct method!
30 sec after the above
tracing, Ao was added & true
end-expiration clearly
identified.

31. 31
40
30
20
10
0
-10
Same patient 20 minutes later
40
30
20
10
0
-10

32. 32
15
10
5
0
-5
CVP=13

33. Summary
• Record Ao with CVP
• Read mean CVP at end-expiration as described. No need read
vascular pressure at any particular time in the cardiac cycle
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34. Documentation of CVP
• Include on waveform strip
• Position of the HOB
• Vasopressors and rates
• Amount of PEEP
• Scale
• CVP measurement
• Signature of the nurse
(post in green chart behind graphics tab)
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35. References & Resources
Burns, S. M. (2004). Continuous airway pressure monitoring. Critical Care Nurse, 24(6), 70-74.
Chulay, M., & Burns, S. M. (2006). AACN Essentials of critical care. McGraw-Hill: New York.
Edwards. (2006). Pulmonary Artery Catheter Educational Project. http://www.pacep.org
Edwards Lifesciences. (n.d.) Educational videos. www.edwards.com
MICU Routine Practice Guidelines. www.vanderbiltmicu.com
MICU Bedside Resource Books
MICU Education Kits (Red cart in conference room)
MICU Preceptors, Help All Nurses, & Charge Nurses
VUMC policies. http://vumcpolicies.mc.vanderbilt.edu
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